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Using Technology to Level the Playing Field to Close the #DigitalDivide

June 10, 2020

Q1 How can we track telemedicine usual to ensure that access to care and disparities don’t worsen?

A1 Notable Responses: Jamey Edwards (@jameyedwards) #Telemedicine is inherently measurable as it is digital. We know start time / end time of calls, where calls are originating, type of device. We can layer AI over call data & & track if we treat patients differently. Helen Burstin (@HelenBurstin) This is a critical question since we know that access to tech can be a rate limiting factor. We need to proactively collect data to make sure that all pops can equally access #TelemedNow Janice Tufte (@JaniceTufte) #HealthSystems should require collection of demographic and access data, create incentivizing measures in this area Ceci Connolly (@CeciConnolly) No easy answer here: health orgs must build trust. Will need to have honest conversations w/consumers & community members about what info they are comfortable having tracked/shared. Ritu Thamman (@iamritu) A recent studies tracked #TelemedNow usage before/during #Covid19 & found Less telemedicine use by vulnerable populations. Inaccessible design features, including a lack of focus on culture, literacy, & numeracy, limit the benefits of increased data access & worsen inequities Connie Hwang (@hwangc01) This telehealth analysis by race/ethnicity is both illuminating and concerning. A commitment to measuring for disparities should be core to future telehealth policies and programs. Andy McCullough (@DrAMcCullough) In the last week, after many difficulties I have had scheduling staff identify patients who need translator services, and either changed the e-visit to an in person visit (scheduled later) or a phone call if acute symptoms. Open to other ideas!! Jorge Rodriguez (@translatedmed) Organizational dashboards should include metrics with a equity focus that include use across demographics, including race/ethnicity and language. Ami Bhatt (@AmiBhattMD) We are looking at the patients we served from March to May and assessing where our patients came from and who we are missing. You can all do the same! @NjambiM_MD @kemar_MD and colleagues leading the charge as #ACCFIT !! Ceci Connolly (@CeciConnolly) Consider exploring ways to show consumers how and when data is being used. Transparency & visibility are key to engendering trust. Jorge Rodriguez (@translatedmed) Improved integration of intepreter usage in the context of not only virtual care, but also in-person visits. Unifying clinical data with interpreter data will be key. Salim Saiyed (@SalimCMIO) Use data to track demographic usage of volume - race, ethnicity, zipcode. Track no shows to follow up with patients to identify "#digitalgaps". it takes picking up the phone, identifying the issue & closing those gaps. Find family, friends, neighbors to help. Matt Sakumoto (@MattSakumoto) Track age, race/eth, other #SDOH for in-person, telephone, video visits. They *should* be roughly equal - if not, that's the start point to address access/literacy/cost #TelemedNow Jorge Rodriguez (@translatedmed) Make sure we capture qualitative data (patient experience/satisfaction) to support our quantitative findings. Brittany Patridge (@bspartridgeCIS) And have the ability to provide technical support in a language they understand. We have implemented Interpreters into our Video Visits....now time to integrate them into our help desks? Andrew Watson (@arwmd) Yes, and the entire concept of customer or digital support is such an important topic. It was more challenging than many thought once Telemedicine was in full swing during the month of April. Jagdish Patel (@jpkca) Disparities vs inequities. Health Disparities:differences in the presence of disease, health outcomes, or access to health care between population groups. Andrew Watson (@arwmd) It would be nice if and users would offer demographic information, and even raise. ZIP Code would be quite important. Also, whether or not they have insurance and social determinants of health type questions. #TelemedNow. Bruce Rollman at UPMC Has looked at this data.

POLL 1: Does your clinic routinely screen for connectivity when patients reach the front desk? (Does your clinic know which families can easily videoconference, and which are sharing a limited number of monthly minutes on a smartphone?) Q2 How can we make #access to #Telemedicine easier for racial and ethnic groups? A2 Notable Responses: Matt Sakumoto (@MattSakumoto) For limited english proficiency pts, proactive outreach in native language is key (with video interp when possible). Access by race/ethnicity is a complex one - is it insurance, internet/phone access, ltd # of phone minutes, shared family phone? Research needed. #telemednow Jamey Edwards (@jameyedwards) For those who don't have a #smartphone or #broadband access, #telemedicine can decompress local urgent care / ER resources so clinicians are available in a timely fashion. Remember that a phone can be a viable modality. Salim Saiyed (@SalimCMIO) #telemednow has to become a covered service by @CMSGov & #medicaid To further make it easier, we need to track data to show disparities. We need coverage for devices. health insurance covers transport to brick & mortar. They must cover devices, data to receive telemedicine. Janice Tufte (@JaniceTufte) Join the Broadband Research base Digital Inclusion Alliance https://digitalinclusion.org/broadband-research-base/ learn from others, ask questions reach out to the people in the know from the communities and individuals themselves #TelemedNow #PatientsFirst also @FCC Keep Americans Connected Pledge Ami Bhatt (@AmiBhattMD) We used to say these things take time, but #COVID19 showed us that the government can be agile!! Time to decide that #broadband is an essential community need #TelemedNow @arwmd @HelenBurstin @CNNPR @AjitPaiFCC @RepJoeKennedy Jamey Edwards (@jameyedwards) (1 of 3): #Telemedicine increases access by bringing high quality #healthcare into underserved communities. This starts with hospitals & call panels for much needed services (stroke, psychiatry & more) including #interpreters... Jamey Edwards (@jameyedwards) (2 of 3): #Telehealth also mitigates the need for transportation, keeping low acuity cases home & managing chronic conditions, some of which fall disproportionately on the underserved such as diabetes due to lack of access to healthy food options. Jamey Edwards (@jameyedwards) (3 of 3): For those who don't have a #smartphone or #broadband access, #telemedicine can decompress local urgent care / ER resources so clinicians are available in a timely fashion. Remember that a phone can be a viable modality. Andy McCullough (@DrAMcCullough) #TelemedNow Nothing reveals the importance of the telephone call like a failed video visit. Ceci Connolly (@CeciConnolly) Important to remember #virtualcare is still #healthcare. Community outreach, partnering w/ local trusted voices in community, building relationships really matter. #TelemedNow Ceci Connolly (@CeciConnolly) Plans like @ucaremn and @_HealthPartners have had success developing new programs when working w/Somali pops because they focus on building strong relationships. THAT should be the model for any health program, including #telehealth #TelemedNow Ami Bhatt (@AmiBhattMD) #TelemedNow needs to be easier for all. There need to be 24h help lines just like for any other consumer industry. Matt Sakumoto (@MattSakumoto) Meet the pt where they are at - bring the Pop-Up telemed to the patient - church, barbershop, YMCA. An iPad, RN and vitals cart = mobile community clinic #TelemedNow Ryan Jelinek (@RJelinek) #TelemedNow knowing that their is going to be hardware and broadband carriers for the foreseeable future, we need to meet patients where they are. The concept of pop-up telemedicine “clinics” could get you there. VA is working on ATLAS along those lines Ami Bhatt (@AmiBhattMD) For at risk populations, we need tablet donations from @amazon @Apple @BestBuy and others, and then we need to boost WiFi and create community centers and local "virtual clinics" #TelemedNow #equity #community Ritu Thamman (@iamritu) VA’s Offices of Rural Health &Connected Care pilot distributed video-enabled tablets to veterans who did not have the necessary technology & who had geographic, clinical, or social barrier to in-person health care access: https://pharmastrategic.wordpress.com/2020/04/15/patient-perceptions-of-video-visits-using-veterans-affairs-telehealth-tablets-survey-study/ Andrew Watson (@arwmd) I completely agree about donating technology to populations at risk. Ceci Connolly (@CeciConnolly) I agree too but also want to see govt & biz investment #TelemedNow Lisa Levitt (@llevitt800) When I was planning #telehealth for #Medicaid, there were opportunities to fund equipment through corporate donations and grants for vulnerable populations. There are older tech models that can still work well for #virtualcare even if less desirable for retail market. Jagdish Patel (@jpkca) We may need to be more creative how to cover special group. Options are... may be more 1 can have few spots daily weekly for special group 2 We can for a alliance dedicated to TM for minorities 3. PCP days, specialist days etc Brittany Patridge (@bspartridgeCIS) I like the idea of pop-up clinics for those that don't have phones or broadband etc. I just hope they are considering where to place those so that access isn't still a barrier. I have always felt the public libraries would be a great spot for a telemedicine kit #Telemednow Jagdish Patel (@jpkca) Factors creating lack of access of health care to minorities are so many.. transportation Ignorance Money lack of insurance Health education Andy McCullough (@DrAMcCullough) In this study by @sri_adu and others @PennMedicine Median household income <50k and Non-English language speaking patients were independently associated with >50% less video use. @noshreza Jagdish Patel (@jpkca) One of the sad fact is many practices has stayed away accepting Medicaid. Hope those providers would change their view and be part of #Telemedicine Connie Hwang (@hwangc01) Over 200 iPads were purchased by @ucaremn to support #telehealth & video connections for seniors @ NHs and Assisted Living Facilities. The demand for tablets was far greater than expected, helping address social isolation & new ways to connect with loved ones. #TelemedNow @_ACHPz Jagdish Patel (@jpkca) I don't hear much about IBM Watson? I wish it would be part of #Telemedicine Annette Ansong (@kiddiehearts) Educate, educate, educate. Go where the patients are. In the Black community, this would be churches, barbershops, hair salons, Black civic groups, Black-Greek lettered organizations,etc. Get the word out that #TelemedNow is a doable means of improving your health. Q3 Should we make uniform clinic level protocols/health care protocols for Racial/SES equalities in Telemedicine? Should interpreter services during virtual care be standard? A3 Notable Responses: Andy McCullough (@DrAMcCullough) We need standardization of protocols and dissemination of access. Without reliable methods of communication we will invariably miss worsening disease in already disadvantaged populations. Janice Tufte (@JaniceTufte) #Equity in healthcare should be an imperative not a choice, standardized option(S) for #TelemedNow included. Interpretation services should be offered to meet #ADA regulations including technology not only for medical care Salim Saiyed (@SalimCMIO) We need universal protocol for #equalities, so that not everyone is trying to invent it - Using Interpreters over #TelemedNow can be difficult. Lets teach everyone #bestpractices - Do interpreters even realize all of sudden they are being use in a three way conference ? Ami Bhatt (@AmiBhattMD) #interpreters must be standard of care for #Telemedicine ... if they are not available, it would be the same as not offering them in a clinic setting. It's not easy. But it's right. #TelemedNow This is a great article about the right to interpreters https://journalofethics.ama-assn.org/article/clinicians-obligations-use-qualified-medical-interpreters-when-caring-patients-limited-english/2017-03 Jorge Rodriguez (@translatedmed) There are federal mandates/guidelines, including the Cultural and Linguistically Appropriate Services, which make it clear that interpreters are essential to the care of LEP pts. This should be no different in #TelemedNow Matt Sakumoto (@MattSakumoto) Offering any less than Hundred points symbol interpreter coverage for telehealth is unacceptable. Bridging Racial/SES issues is tougher - who should provide most of the $$ for access improvement - clinic, health system, state, FCC, CMS? #TelemedNow Jagdish Patel (@jpkca) Interpreter service would be great to have. It will relieve so much anxiety for patient and family Helen Burstin (@HelenBurstin) Standard access to interpreter services for LEP patients is already required. For #TelemedNow, we can't risk "clinicians skating by without interpreters as they make the transition to virtual care" as @translatedmed shared in this compelling article: https://www.theverge.com/21277936/telehealth-english-systems-disparities-interpreters-online-doctor-appointments Faisal Qureshi (@fqure) #Telemednow is a direct reflection of in person protocols. If your doctor never had an interpreter, telemed won’t change that. That said, huge new opp for online interventional interpreter services that can scale to make it worthwhile for pts and providers. Jennifer Co-Vu (@DrJenniferCo_Vu) We don’t just need standard interpreter services for non-English speaking patients but also for deaf/mute patients, who also had increased access to care now with the availability of video telemedicine vs just telephonic.

POLL 2: Do you assess #Digital #healthliteracy (the degree a patient can obtain, process,& understand digital services & information) in your clinic or at a #Telemedicine visit ? POLL 2 Reply: Ceci Connolly (@CeciConnolly) I rarely hear mention of this happening but it seems so fundamental. Of course many of the people lacking digital health literacy may not be encountering clinicians at all. The gaps are wide Q4 How can we improve #broadband access for more adoption among different racial and ethnic groups?

A4 Notable Responses: Jamey Edwards (@jameyedwards) Clinical protocols need to take into account #culturalcompetency as acceptable customs & traditions may vary. We have been talking about doing this right in #healthcare for a long-time, but our practice can be better. https://www.aha.org/system/files/hpoe/Reports-HPOE/becoming-culturally-competent-health-care-organization.PDF bloomrhealth@bloomrhealth) Governments have a huge part to play in this and I am sure private industry will innovate and follow #TelemedNow Andrew Watson (@arwmd) Do we know of a broadband map that indicates any sense of healthcare capacity? I’m sure Ajit has a broadband map in general, do we need something more healthcare specific? Is the juice worth the squeeze? #TelemedNow Ie bandwidth and hardware endpoint? Ami Bhatt (@AmiBhattMD) Here is the FCC Connect2Health map ... https://www.fcc.gov/reports-research/maps/connect2health/#ll=40,-95&z=4&t=insights&inb=in_bb_access&inh=in_diabetes_rate&dmf=none&inc=none&slb=90,100&slh=10,22 Jamey Edward (@jameyedwards) @CloudbreakHLTH built one of the largest networks connecting #healthcare in the country. 1,200 facilities are on nationwide rural and urban alike. Ritu Thamman (@iamritu) some have turned to building their own networks rather than waiting on private, incumbent ISPs who lobby against these community broadband networks, which include municipal/public option networks, serve > 900 communities across Ceci Connolly (@CeciConnolly) Access is a critical issue & cost/availability of broadband is a huge barrier. Health organizations should be allies in push for better IT infrastructure. But organizations can also take immediate action their community. #TelemedNow Ami Bhatt (@AmiBhattMD) There are great examples of ongoing legislation! #TelemedNow Look at Iowa: https://cbs2iowa.com/news/local/legislation-aimed-at-improving-rural-broadband-access-clears-house-and-senate Helen Burstin (@HelenBurstin) We need to advocate for broadband access for all. In the meantime, we need to ensure #TelemedNow pay parity for both telephone and video visits (including Medicaid)! Lisa Levitt (@llevitt800) for broadband access we need to factor in planned transition from 4G to 5G. Suggest maintaining 4G option until 5G compatible gadgets are affordable. Older equipment will not work on 5G. Matt Sakumoto (@MattSakumoto) For what it's worth SMS-based patient outreach really helped with rollout of Obama-phones. Is there a smartphone/data plan equivalent that can be deployed today at low/no cost to families in need of access? Jamey Edward (@jameyedwards) State Telehealth Resource Centers have been helping here but more needs to be done. This type of infrastructure is more easily solved by gov't than by private sector. FDA Distance learning grants have helped to fund as well. Still miles to go before I tweet.... Andy McCullough (@DrAMcCullough) This is tough because it is usually out of the physicians hands, and broadband is (1) expensive - cost and equipment (2) requires housing, and (3) a device to access it. Luckily my representative is @AOC and regularly works to improve disparities Ami Bhatt (@AmiBhattMD) This is a great effort ongoing in New Hampshire! It is our role as clinicians to support these state level efforts to improve #broadband #access ... we don't need to recreate the wheel ! https://www.conwaydailysun.com/opinion/letters/cynthia-stanton-vote-yes-to-broadband-access-on-the-nh-electric-coop-ballot/article_980c1784-a5c4-11ea-8fc4-874802236797.html Q5 How to best use Asynchronous Communications to improve HTN & DM control in minorities ?

A5 Notable Responses: Jamey Edward (@jameyedwards) #Asynchronous #Telemedicine offers many opportunities to aid in Hypertension & Diabetes especially w/ #RPM. #Telehealth can signal times for intervention & prevent acute situations. Can also access dieticians & other resources not avail otherwise. Ami Bhatt (@AmiBhattMD) As we think about #nutrition in these at-risk populations, questionnaires about #foodinsecurity should dovetail with these #virtualcare and #virtualeducation efforts Helen Burstin (@HelenBurstin) We need to automatically get data from pt devices (glucometer, BP, scale) in a format that allows pts and clinicians to see trends over time, especially after med changes. Chronic care monitoring, mgt, & outcomes is our #TelemedNow topic for next week! Andrew Watson (@arwmd) The only challenge with automatic is the pairing of the device with the cell phone. That can create a lot of headaches for hospitals and doctors. We’re learning this right now at UPMC. Jagdish Patel (@jpkca) DM is the biggest problem. DM with complication puts pt in a lifetime struggle. It requires multi-modalities approach Ritu Thamman (@iamritu) Another study looking at DM pts who had known CAD Used text messages & improved glycemic control in a RCT https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.119.005805 Jamey Edward (@jameyedwards) Asynch & Synch #Telemedicine need to available widely on multiple consumer platforms (#iOS, #Android, #PC) & ideally not require specialty hardware that may be expensive or hard to come by. A practical approach beats sizzle every time. #Phone & #TV are ubiquitous. Jagdish Patel (@jpkca) DM without complication can be done with asynchronous approach using data transmission, home health care #RPM RPM can play big role Ritu Thamman (@iamritu) Simplicity is the real key to telemedicine #TelemedNow Matt Sakumoto (@MattSakumoto) Many players in the data aggregation space @Tidepool_org for diabetes, @fitbit, @apple HealthKit and more - look forward to hearing the hive mind recommendations! #TelemedNow Jim St.Clair (@jstclair1) Recognize their is still concern (as I understand ) in clinical quality of data from 3rd pty devices #TelemedNow Ceci Connolly (@CeciConnolly) Apologies for a bit of redundancy this evening but reaching minority communities/underserved pops starts w/trust. From that, much more will flow nicely #TelemedNow Matt Sakumoto (@MattSakumoto) Thank you for recognizing the *non-video* aspects of #telehealth! So much opportunity in the asynchronous space - to expand care beyond clinic walls, and beyond normal clinic hours. #telemednow Andy McCullough (@DrAMcCullough) Here is where I have found using my institutional email and/or the phone appointment very effective. Take the BP for 10 days and email it to me - I will email you back or call you with recommendations. Can be applied to DM care as well. Janice Tufte (@Hassanah2017) Asynchronous teleconsultation can be thoughtfully developed for healthcare #information and #education, diet and nutrition opportunities and disease management in HTN and DM #TelemedNow Matt Sakumoto (@MattSakumoto) Health Navigators can help pts trend/upload their BP/Glu. Med change can be done async and save the pt a trip to office (and less time off work) #TelemedNow

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